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May 2020
Ethical Considerations in Relaxing COVID-19 Restrictions

As national, state and institutional policymakers wrestle with the question of when and how to reopen society, questions arise about how best to both assess and balance the risks, costs and benefits of safely restarting the economy while simultaneously containing the spread of COVID-19. These are very much ethical decisions as much as they are economic and public health policy decisions. We have compiled a number of thought-provoking articles to explore the myriad considerations involved in mapping out a plan forward.

DNR/COLST Update: Documentation of a Clinician's Verbal Order

The Vermont EMS protocol has recently been updated to indicate that documentation of a clinician signature as a “verbal order” on the Vermont DNR/COLST form is considered acceptable and will be  honored by EMS. In order for a clinician’s verbal order signature on the  DNR/COLST form to be valid, the following is required:

  • The patient’s nurse or social worker must print the clinician’s name in Section A6 for DNR and/or Section H for COLST and write “Verbal Order” on the clinician signature line.
  • The nurse or social worker documenting the verbal order must also sign and date the form.
  • A duplicate DNR/COLST must be completed and sent to the clinician for an original signature.
  • At the earliest convenience, the order with the original signature must be returned to the patient to replace the previously documented verbal order.
Advance Directive Update: Remote Witnessing During COVID-19

Vermont Ethics Network is working with policy makers and a number of interested stakeholders on legislation to allow remote witnessing and explaining (if applicable) of advance directives during the COVID-19 Emergency. House bill H.950 is currently making its way through the legislative process. While this happens, we offer the following recommendations for completing an advance directive during this time of social distancing:

  1. Talk to your family and friends about what matters most to you and ask someone you trust to be your health care agent.
  2. Choose the form that works best for you and write down your health care goals and priorities.
  3. Identify 2 adults willing to serve as remote witnesses. Please note that witnesses cannot be your agent, spouse, parents, siblings, adult children or grandchildren. For remote witnessing, they must be someone you know. Your health care provider may serve as a witness.
  4. Have your witnesses be on the phone or a video chat and tell them “by being my remote witness you are attesting to the fact that I, the principal, seemed to understand the nature and effect of the advance directive and was free from duress or undue influence at the time of signing”. 
  5. Sign and date your document.
  6. Write each remote witness’ name, phone number, relationship to you (i.e. friend, neighbor, work colleague, etc.), and the date on the document.
  7. In the witness signature line, write “verbal witness per COVID-19” if witnessed via telephone discussion, or write “video witness per COVID-19” if witnessed via video conferencing.

We will post information on the VEN website and in upcoming newsletters/announcements if House bill H.950 is passed into law. In the meantime, the steps described above represent the best way to document your wishes during the COVID-19 state of emergency so that you can share them with your health care providers, health care agent and those closest to you. 

Presently, documents completed during this time do not meet with the letter of the law, but they still carry moral weight and will be considered if a situation arises where you cannot make health care decisions for yourself. Health care agents and surrogates are obligated to make decisions based on what they know is important to you and what they believe you would say if you were able. Information you provide in your document will help them to make care and treatment decisions that align with your goals and preferences. Health care providers and hospitals have autonomy-based obligations to honor preferences you expressed at a time of capacity to the best of their ability.
 
If you create a document using remote witnesses, you should be prepared to complete a replacement advance directive with in-person witnesses as soon as it's safe to do so.
COVID-19 Resources on VEN Site

VEN has assembled a wide range of resources to support the Vermont community, health care providers and facilities as they seek to navigate needs and decisions associated with COVID-19. A few of these resources are highlighted below and more comprehensive lists can be accessed via the subsequent buttons.

Community Resources

Health Care Provider and Facility Resources

From the Frontlines
Free Public Information Sessions About Advance Directives

Every Wednesday from 10-11 am, beginning May 6, 2020, Brattleboro Area Hospice’s Taking Steps Brattleboro program will host an Advance Care Planning/Advance Directive Question and Answer Information Session via Zoom. Interested individuals are encouraged to attend an informational session to ask questions about how to complete an advance directive, including where to find forms, who should be named as a healthcare agent, who to give the completed form to, and how to talk with family about your healthcare wishes in preparation for a time at which you may be unable to speak for yourself. Anyone 18 years of age or older should have a completed advance directive.

If you are interested in attending, please contact Don Freeman (802-257-0775, ext 101) in order to receive the emailed Zoom invitation and/or call-in number. 
Regional Advance Care Planning Support

Since the COVID-19 crisis began, VEN has been receiving a higher number of calls from individuals seeking to complete an advance directive. In order to best support those who are seeking one-on-one guidance, we have reached out to our network of partners across the state to identify contacts by region who are available to provide this support remotely by phone or video conference. To access this list, please click here or visit the link below.

If you are an individual seeking advance care planning support, we encourage you to connect with the contact(s) listed for your region.

If you represent an organization that has staff or volunteers available to provide remote advance care planning support and are not yet listed, please contact us to be added.
VEN Spring Conference Postponed

In light of COVID-19 concerns, our May 18 Palliative Care Conference has been postponed. We are hoping to reschedule for the fall and will send notice of a new date once it is identified.
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HEALTH DECISIONS is a publication of the Vermont Ethics Network.

The mission of the Vermont Ethics Network is to advance ethics in health care.
Board of Directors
Geraldine Amori, PhD
E. Tobias Balivet, Esq.
Linda Cohen, JD, MHCDS
Linda Hurley, RN, MS
Alden Launer, MDiv
Peg Maffitt
Kier Olsen DeVries, MA
Martha Richardson
Hilary Ryder, MD
Staff
Cindy Bruzzese, MPA, MSB
Executive Director and Clinical Ethicist

Catrina Brackett
Executive Admin/Bookkeeper

Honorary Board Members
James L. Bernat, MD
Michelle Champoux, LICSW
Jean Mallary, RN
Robert Macauley, MD